6/27/2016

Practical Intro to EKGs

Reid B. Blackwelder, M.D.

(blackwel@etsu.edu)
Professor, Family Medicine
East Tennessee State University

Goals Basics - Physiology

Learn basic approach to any EKG
The heartbeat creates many cellular depolarizations
Develop foundation knowledge
When going toward positive leads, get
Connect with anatomy, physiology
Positive deflections
Create a system for practice
When going away from positive leads, get
Practice practical implementation
Negative deflections
Amaze your Friends (and your attendings)!
EKG is a summation measurement of many cellular
Save your patients! events

Basics Alphabet Review Alphabet

PR Interval ST Segment
The first upward deflection is the P wave P wave
It represents atrial depolarization T wave
The PR Interval is the time between atrial and
ventricular depolarization
The QRS complex represents ventricular
depolarization
The ST segment is next
The T wave represents ventricular repolarization QRS

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QRS Nomenclature Examples of QRS Complexes

Upward deflection is an R wave
A second positive deflection is given a prime
designation - RSR
A downward deflection preceding an R is a Q wave
A downward deflection that follows an R is an S wave
If only negative deflection is present it is a QS complex
Ventricular depolarization is called QRS
Although not all parts may be present

Basics - Standards Basics Standard Form

Three limb leads I aVR V1 V4
I, II, III
Three augmented limb leads II aVL V2 V5
aVR, aVL, aVF
Six chest leads III aVF V3 V6
V1-V6
Rhythm strip (II or V 1, usually the atrial leads)

Basics - Strip Review of Boxes

Big box =
200 msec (0.2 sec)
5 small boxes
Little box =
40 msec (0.04 sec)
Also 1 mm

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The System
Only one of many ways to do this!
Caveats
We will not cover Cool Arrhythmias
Remembering criteria is not expected
Or even encouraged until youre ready
Shoot for Normal vs. Not Normal
The only pattern to learn is Normal!
You have everything in the handout
Keep Calm and Carry On!
Review
Validity
Rate
Rhythm
Axis
Hypertrophy
Ischemia/Infarction
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Caveats
Difficult to do in groups
Everyone is at a different level
Lots of material in a compressed session
Your brain will get full before we finish!
The handout is more complete than you
need
The Basic Structure
Validity
Rate
Rhythm
Axis
Hypertrophy
Ischemia/Infarction
Validity
Clinical context for test, right patient, etc
When handed an EKG, ask
Why was this done? and
How is the patient?
Look for voltage standardization curve
Two big boxes tall, or 10 mm/mV
Is also at the bottom of the strip
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Standardization Box Validity

QRS in Lead I should be opposite that in AVR
And QRS is + in Lead I
R-wave should progress in chest (V) leads such
that by V4 the R-wave is most prominent
Represents the left ventricle
Review an old EKG

Validity Poor R wave progression

An issue noted in validity does not necessarily mean

the tracing is invalid
Any abnormalities should generate Differential Differential Dx?
Diagnoses

Validity Visuals Review of Validity

Name, clinical context
Standardization box
QRS in I and aVR generally
opposite
R wave progresses in chest leads
Compare with old EKG

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Rate
Rate
Normal rate 60-100
<60 bradycardia Rate=300/# of large boxes between R-
>100 tachycardia waves, or
Basic pacing rates: Memorize:
Atria 80/min 300, 150, 100, 75, 60, 50, 43, 37
Junctional 60/min Count at each large box after first R
Ventricular 40/min
But a rate does NOT determine pacer

Review of Rate
Rate Calculation 300
150
300 150
100
75 100
75
60
50
43
37

Cumulative Review
The heart rate is closest to: Validity
1. 150 Context
Standardization box
2. 100 I and aVR
3. 75 R wave progression
4. 60 Old EKG
5. 50 Rate
300, 150, 100, 75, 60, 50, 43, 37

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Rhythm Basic Questions
Is it REGULAR?
Is it SINUS?
What are the INTERVALS?
PR
QRS
QT
Rhythm - Regularity
Regular (usually Fairly regular)
Regularly irregular
Group or pattern beating
Predictable
Irregularly irregular
Chaotic
Unpredictable
Rhythm - Sinus
A positive P wave in II
A pacer from the SA node (sinus)
should always be positive if
Leads placed correctly and
No dextrocardia
The why is a Pearl
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Rate & Rhythm
Truly done as Gestalt
Learning steps so you will usually
Implement by steps (with pauses)
How to cut your time in half!
Look at rhythm strip for both
Trust your eyes for not normal
Rhythm - Sinus
Often hear: P before QRS, QRS after P
This really means an atrial relationship
to ventricles
What are the Atrial leads?
For SINUS rhythm must also have
Rhythm - Sinus
Wide vs. Narrow QRS is clinically
important
Covered in Handout
Not covered here
Next level after Foundation work
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Rhythm - Intervals PR Interval

Start
Check PR interval
Start of P to start of QRS
Normal is 0.12-0.20 sec
3 5 small boxes

Finish at 4 small boxes: 0.16

Rhythm - Intervals Rhythm - Intervals

First degree AV block, PR > .20
Second degree AV block Really cool stuff!!
Mobitz type I (Wenkebach) We wont talk about it
Mobitz type II Get the basics down before taking
Third degree AV block on weird rhythms
PR interval can also be too fast
Accessory pathway
WPW, LGL, etc

By the Way Rhythm - Intervals

First Check QRS width
Validity Start of complex to end
Second Normal 0.10- 0.12
Rate 2 to 3 small boxes
Third Look at QRS morphology, too
Rhythm Should be crisp, single line

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QRS Interval Rhythm - Intervals

Start If QRS is wide, then
By definition a Bundle Branch Block
RSR`
in V 1, V 2 is RBBB
in V 5, V 6 is LBBB
Finish at 2 small boxes: 0.08 sec

Rhythm - Intervals Rhythm - Intervals

If RSR` present, or Interventricular Conduction Delay
QRS is slurred or has shoulder, but IVCD, or
Interval not wide or prolonged Early BBB, or
Incomplete BBB
Clinical Relevance?

Shoulder
IVCD Rhythm - Intervals
Handout has more on
BBB
IVCD
Hemiblocks
Not foundation material

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Rhythm - Intervals
QT Interval
Check QT interval
Start of QRS to end of T Rate about 80, so First R
Second R
Depolarization to repolarization
For rate between 60 - 100,
QT < 1/2 R-R interval
Around 0.36-0.44 sec
Very clinically important Halfway: 0.36
R on T phenomenon

Validity Cumulative Review

Is this a sinus rhythm? Context
Standardization box
I and aVR
1. Yes R wave progression
2. No Old EKG
Rate
300, 150, 100, 75, 60, 50, 43, 37
Rhythm
Regular or not
Sinus or not
Intervals

Axis
Use I and aVF for quick scan
Brain Alert! The thumb method
Normal is + QRS in both
Two thumbs up
Its getting full
+ in I, - in aVF
Left Axis Deviation (LAD)

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Axis In which Quadrant is the Axis?

- in I, + in aVF
Right Axis Deviation (RAD)
- in I, - in aVF
Really not normal!
Differential?

Axis Axis
I I+
Main goal now is to identify normal axis or not
F F
But work to be more specific with respect to
Indeterminate LAD
degree of axis
Why?
I I+
F+ F+
RAD Normal

Axis Axis
Normal: 0 to+90 degrees Strive to give degree measurement
Leftward (or LAD) 0 to -29 Look for isoelectric lead
LAD: -30 or more degrees As much + as deflection
RAD: > or = +90 degrees The axis is perpendicular to it

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Axis 12 Lead Basic Form

Perpendicular leads without the graph Perpendicular Leads Cool Trick!
Use the 12 lead structure (all leads in 30) I aVR
I and aVF
Degrees 0 and 90
II and aVL II aVL

Degrees 60 and -30

III and aVR
III aVF
Degrees 120 and 30

Positive in I What is the Axis?

The axis is in which quadrant?
1. Normal
Most isoelectric
2. LAD
Perpendicular lead 3. RAD
4. Indeterminate
5. Not sure

Positive in aVF

Hypertrophy - Atrial
Hypertrophy Normal P wave
Atrial Smooth in morphology
Must have sinus rhythm! < 2 small boxes high and wide (II)
Look at P wave in leads II and V 1 In V 1
Ventricular (Many criteria exist) Can be all positive
Cannot do with a BBB Can be symmetrically biphasic
Left atrium has a little more muscle
Look at QRS in chest leads
Determines time of conduction

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Hypertrophy - Atrial P Wave of RAA

RAA
Lead II:
Tall P-wave (>2.5 mm)
P-pulmonale
V 1:
Large tall P
Tall in both!

Hypertrophy - Atrial P Waves of LAA

LAA
Lead II:
P-wave with notching
P-mitrale
V1:
Mainly or purely negative P-wave

Hypertrophy - Ventricular Hypertrophy - Ventricular

Multiple criteria exist
Included in handout
Trust your eyes for size
RVH
Found in validity evaluation
Big" R wave in V 1 (6-7 mm)
Normal pattern: No R in V1
Deep S wave in V 6 (6-7 mm)
Normal pattern: No S in V6
Included in differential of RAD

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Hypertrophy - Ventricular LVH Example

LVH
Suggested in first scan of EKG Deepest S: 18 mm
One method (Sokolow) is to
Look at biggest R in V 5 or V 6, plus
Biggest S in V 1 or V2 Tallest R: 40 mm
LVH suggested if > 35mm in adult

What hypertrophy is suggested in V1?

1. None
2. LAE Major Brain Default
3. RAE
4. LVH Overload imminent!
Abort!
5. RVH

Basic Cumulative Review Ischemia/Infarction

Validity Check all leads for:
Rate Q waves
Rhythm ST segment changes
Axis T wave changes
Hypertrophy Look in groups of leads

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T Waves ST Segment Changes

Usually QRS and T are upright together Differential for ST Depression
T waves should be upright in V 2-6 Ischemia
Can be normally inverted in V 1 Subendocardial infarct
T wave inversion is first sign of ischemia Strain from hypertrophy
Peaked T wave is first sign of acute injury Drug effect
or high K+ Digoxin

Changes of Ischemia ST Segment Changes

ST depression
T wave inversion
Elevation is Acute injury
If no Q waves then non-Q wave infarction
If associated with Q waves
Likely transmural infarct
Much less common now - thrombolytics

Non Q Wave Infarction Summary of Changes

Repolarization most sensitive part of cycle
Now called
T wave changes are first
Non-ST Elevation MI or
ST segment follows T wave
NSTEMI
Q waves can be bad, but also normal!

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Dynamic Summary Dynamic Summary

The Dance Ischemia:
Visual demonstration T wave inversion, pulls
ST segment down (depression)
If continues, then

Dynamic Summary Dynamic Summary

Injury: T wave inverts again (tombstoning)
T wave peaks (hyperacute T wave), If continues, then
which pulls
ST segment up (elevation) Infarction
Represents Cardiac muscle at risk
If injury continues, then

Dynamic Summary Dynamic Summary

Infarction: The whole process is a continuum
Q wave appears (irrev cell death) Acute Coronary Syndrome
If continues Includes angina
Q wave enlarges and ST seg returns Ischemia
to baseline Injury
T wave inversion is the last thing to Infarction
return to "normal"

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Q/ST changes in Lead Groups (Artery)

Septal (LAD): This EKG suggests
Changes in V1-V2
Anterior (LAD): 1. Normal
V3-V4 2. Anterior MI
Lateral (Circumflex): 3. Lateral MI
I, aVL, V5-V6 4. Septal
ischemia
Inferior (RCA or Circumflex):
5. Inferolateral
II, III, aVF
ischemia
Posterior (RCA):Large R with ST depression V1, V2

Summary
Validity
Captain, shes gonna blow! Context
Standardization box
I and aVR
Not to worry
R wave progression
You now know this stuff
Compare with old EKG

Summary Summary
Rate
300
Rhythm
150
Regular or not
100
75 Sinus or not
60 Intervals evaluated
50 PR
43 QRS
37 QT

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Summary Summary

Axis Hypertrophy
I and aVF Atrial
Normal Quadrant or Not (Axis Deviation) Look at P wave in leads II and V 1
Isoelectric lead next to get degree of axis Ventricular
Work to give degree measurement! Many criteria exist

Summary Thats Enough!

Ischemia
T wave inversion
ST segment depressed
Injury
Now, be careful out there!
Peaked T wave (maybe)
ST segment elevated (maybe)
Cell death
Q wave forms

Let your voice be heard

Evaluate workshops:

Q&A NC App

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